MEDICARE: HAVASU MEDICAL CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1033109863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVASU MEDICAL CARE

Provider Business Mailing Address
First Line	:	1955 MCCULLOCH BLVD N
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5748
Country	:	US
Telephone Number	:	928-453-3007
Fax Number	:	928-680-9663

Provider Business Practice Location Address
First Line	:	1955 MCCULLOCH BLVD N
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5748
Country	:	US
Telephone Number	:	928-453-3007
Fax Number	:	928-680-9663

Authorized Official
Title or Position	:	M.D.
Name	:	DR. MARY LOU CALLERAME II
Credential	:	M.D.
Telephone Number	:	928-453-3007

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	11/18/2009

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